Training ANAESTHETISTS in Europe (UK)
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Training ANAESTHETISTS in Europe (UK) . Monty G Mythen Portex Professor of Anaesthesia and Critical Care. Director, Centre for Anaesthesia, Critical Care and Pain Management. University College London, UK. Centre for Anaesthesia. UCL. “ Two Great Countries Separated by a Common Language”

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Training ANAESTHETISTS in Europe (UK)

Monty G Mythen

Portex Professor of Anaesthesia and Critical Care.

Director, Centre for Anaesthesia, Critical Care and Pain Management.

University College London, UK

Centre for Anaesthesia

UCL



Anaesthesia in europe uk l.jpg

How convince Anesthesiologists to go outside the O.R?

Is it all economics?

Challenges in training and future plans?

Non-physician Anesthetists?

Anaesthesia in Europe (UK)


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Marathon des Sables

  • Extreme endurance event- several hours/ day

  • Thermal challenge

  • Fluid loss

  • Electrolyte imbalance

  • Acute inflammatory response


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Marathon des Tables

  • Extreme endurance event- several hours / days

  • Thermal challenge

  • Fluid loss

  • Electrolyte imbalance

  • Acute inflammatory response


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How convince Anesthesiologists to go outside the O.R?

Is it all economics?

Anaesthesia in Europe (UK)

YES – BUT!


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Critical Care – 90% Anesthetists

Pain – Acute and Chronic – 95% Anesthetists

Pre-op evaluation

Critical Care Outreach

Management

Anesthesia Outside the OR?


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National Health Service

National Pay Scale

No Billing!

ALL Doctors paid same

Term pension

Funding in UK?

  • Private Practice

    • Inflated hourly rates

    • Direct Patient Billing

    • Symbiotic relationship


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Critical Care* – 90% Anesthetists

Pain – Acute and Chronic* – 95% Anesthetists

Pre-op evaluation* (replacing cardiology) – “Fit for Surgery”

Critical Care Outreach* (PACU + post-op care)

Management

Anesthesia Outside the OR?

*Doctors: Doctor

*Nurses: Nurse


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How convince Anesthesiologists to go outside the O.R?

Is it all economics?

Challenges in training and future plans?

Non-physician Anesthetists?

Anaesthesia in Europe (UK)


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Med Student 5-6 yr

PRHO (no debts) 1 yr

SHO (non-anesthesia) 1-4yr

Reg. (3 exams FRCA) 4 yr

Research (MD/PhD) 1-3 yr

Senior Registrar 4 yr

Consultant

Training changes in last decade – 10 yrs ago

96 hrs pre week – “undertime”


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National Health Service

Service delivery by senior trainees (post-fellowship)

Consultant led

Funding in UK?

  • Private Practice

    • Consultant delivered


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PRHO 1 yr

SHO (non-anesthesia) 1-4yr

SHO (Anesthesia) 2 yr

Reg. (3 exams FRCA) 4 yr

Research (MD/PhD) 1-3 yr

Senior Registrar 4 yr

Consultant

Training changes in last decade –10 years ago

96 hrs pre week – “undertime”


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PRHO (Modest Debt!) 1 yr

SHO 1-4yr

SpR 5 yr

Consultant

Training changes in last decade - now

48 hrs pre week – “OVERTIME!”

European Working Time Directive

EU – equivalence in training


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National Health Service

Trainees

Consultant delivered (48 h working week)

Funding in UK?

  • Private Practice

    • Consultant delivered

R.O.W

?

N.P.A


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How convince Anesthesiologists to go outside the O.R?

Is it all economics?

Challenges in training and future plans?

Non-physician Anesthetists?

Anaesthesia in Europe (UK)


Non physician anaestheitists in uk l.jpg

Can only work under Physicians

Same as SHO (competent – not “post-fellowship” – NOT “specialists”)

Training controlled by Royal College of Anaesthetists (27 months)

NOT just Nurses

Can not practice independently

1 Consultant : 2 Assistants. Max 2 rooms (Private practice?)

Non-Physician Anaestheitists in UK


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Pre-op evaluation

SHO, pre-fellowship SpR, NPA:

PMH, drugs, allergies, airway etc.

Post fellowship SpR, Consultant:

Is the patient fit for surgery?

MY CLINIC

Special investigations (CPX)

Risk evaluation

Per-op technique

Post –op care

Non-Physician vs Physician


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Whats new in Europe (UK)?

DR Judith Hulf – Vice President R.C.A.

Training?


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Post-Graduate Medical and Education Training Board (PMETB)

Single unifying framework for postgraduate medical education and training

General and Special Medical Practice (Education and Qualifications) Order

Approved by Parliament April 2003


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PMETB

“The order places a duty on PMETB to establish, maintain, and develop standards and requirements relating to postgraduate medical education and training in the UK.”


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PMETB

  • The Board:

  • NHS appointees

  • Chairman, CEO

  • 25 members – 9 lay / 16 medical members

    • 6 Academy of Medical Royal College nominees

    • 4 observers, 1 from each Department of Health


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STAPMETB

* Independent * Accountable Secretary of State

* Certification & regulation body * Wider remit

* Devolved activity to Medical * Will run own activity

Royal College

* Colleges ran own visiting * Will commission own visits programme. Reported to STA to include lay members


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PMETB and Length of Training

Does competency based training still need to be time based?

European minimum recommended training time

Does all “training” need to be completed before the award of a Certificate Completion Training?


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PMETB and the CCT

CCT=CCST

Level of assessed competence in one or more areas of training

What is the minimum training time for a CCT?

“The standard for the award of a CCT should be the same as that currently required for a CCST”


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Foundation Years

-2 year planned programme of general training

-Series of placements - number of specialties

- number of healthcare settings

Demonstration of competence against set standards

Started in August 2005


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Foundation Years

F1 and F2 are generic training

F1 normally works on 3 x 4 month posts

F2, more variety, 3 x 4/12 or 4 x 3/12, but can be individually tailored

Feeds into “general” specialty training

Level of service commitment?

Some specialities have lost their Junior Residents!


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Specialist or GP training

Medical school Two Year Foundation Programme

Provisional Registration GMC

Full Registration GMC


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F2 Curriculum

Case mix suited to be taught by;

Critical Care

A&E

Acute Medicine

Anaesthesia

Oct 2005


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F2 assessments

Overall Pass or Fail – no grades

Mini-Cex (clinical evaluation exercise – 6 observed encounters)

DOPS ( direct observed procedural skills)

Mini-PAT (peer assessment tool)

CbD (case-based discussion)

Expect to identify doctors in difficulty early


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Specialist Training

To be streamlined

Years following F1/2 are Specialist Training (ST) years 1,2 etc

Specialist training years to be “seamless”

ST1 starts in August 2007

Selection process for ST1 will start in December 2006


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Specialist Training

PMETB sets the standards

Apply direct from F2

Competency based curriculum

Defined levels of competence for service delivery

End point is a CCT “Accredited doctor”


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MMC – Possible Foundation

Accredited Specialist (CCT)

Accredited GP (CCT)

Accreditation

Accreditation

Competency Threshold 2

Level 2

Service Posts

(Reformed SAS Grades)

Accredited SpecialistTrainingProgrammes

Accredited GeneralPracticeTrainingProgrammes

Run Through Training

Competency Threshold 1

CompetencyBased Programmes

Level 1

ST Non ProgrammePosts

Enhanced ServiceAppointments

ESA

ST

Foundation Year 2

Foundation Year 1


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Seamless specialty training

Direct Path

Broad-based Path - Common stem programme


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ST1

common stem programmes

ICM

A&E

Acute

medicine

Anaes

thesia

surgery

neuro

sciences

non

acute

medicine

GP

paeds

community

medicine

FY2

FY1

Oct 2005

ICM,acute medicine,

anaesthesia,A&E


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ST1

and beyond

Anaesthesia

ICM,acute medicine,

anaesthesia,A&E

FY2

FY1

Oct 2005


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Seamless training

Choice of specialty needs to be correct for the trainee

Currently 50% drop-out from Anaesthesia at SHO

Choosing a doctor with correct attributes

Selection criteria as yet un-validated


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Keys to Success

Manpower planning

Managing competency-based training

Stopping continual change


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Article 14 and Equivalence

Previously: judged equivalence under Article 9 of the ESMQO

Under the new medical order and PMETB Article 14 takes over the comparison with CCT training

Oct 2005


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Article 14

Country of origin is immaterial

Considers training and experience from anywhere

Ratio T:E is unclear


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Equivalence

144: experience of the applicant measured against the CCST(CCT)

145: experience of the applicant measured against a non-UK specialty

This could equate to a “generic” consultant

or

A non-UK specialty e,g. a cardiac anaesthetist


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145

Have to have done training abroad to fit into this category

( to stop UK trainees taking this route)


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“Any fool can give an Anaesthetic”

Nuffield Chair at Oxford University

“Yes, that’s what worries me!”


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Anaesthetic Grant Application

Dear Sirs:

Despite there never having been any meaningful investment in Anaesthetic research, Anaesthetics always work and are incredibly safe (mortality < 1:100,000). Therefore, please give us millions of Medical Research Council pounds so that we may indulge ourselves in intellectual frippery.

Yours etc.

p.s. if you ever need an operation you will be safe with us


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Cardiology Grant!

Dear Sirs:

Despite having invested millions of Medical Research Council Pounds in Cardiology, heart disease remains the commonest killer in the UK. Little or no progress has been made despite having the most Professors and the biggest departments. However, I have just noticed that very few nematodes die from heart disease and we have just decoded the human genome. Therefore, please continue to give us millions of Medical Research Council pounds so that we may continue to indulge ourselves in intellectual frippery.

Yours etc.

p.s: you will probably die from heart disease





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Dr Paul Older: at UCLHWestern Hospital Melbourne


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How is Anerobic Threshold at UCLH Measured?


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n = 184 at UCLH

Cardiovascular mortality in patients >60yrs undergoing major intrathoracic or intra-abdominal surgery

Chest 1993 104: 701-04


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‘AT’ 600 ml/min 9.7 ml/min/kg at UCLH

This is moderate cardiac failure

but note early onset of ST depression

Early ischaemia -becoming positive within three minutes of onset of exercise and well before AT


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  • at UCLHAT’ 1160 ml/min : 16.5 ml/min/kg

    • No cardiac failure

note onset of ST depression

Late ischaemia -becoming positive late in exercise and occurring around or above the AT



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ICU bed utilisation and mortality per 100 patients over 65 for elective major abdominal surgery

- 15 years of development of preoperative assessment

<1985

<1989

<1992

<1994

<1995

<1996

<1999

100(2)

Number triaged to ICU

40(1)

45(3)

45(3)

36(3)

29(3)

22(3)

Total bed days

600

430

260

225

152

78

66

Average days in ICU

15

4.3

5.7

5.0

4.2

2.7

3.0

Non surgical mortality

19

6

7

4

2

0

0.5

1) all emergency admissions following elective surgery

2) all cases admitted to ICU electively pre-operatively

3) elective admissions according to triage


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Descending Aortic Velocimetry: Oesophageal Doppler? for elective major abdominal surgery


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Intraoperative Fluid Loading guided by Doppler in major non-cardiac (n=100)

Gan et al., Anesthesiology 2002


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